Skin Disorders Guide

Diagnostic Hallmarks

1. Distribution: groin and other intertriginous areas
2. Satellite papules and pustules
3. KOH preparation and fungal culture

Clinical Presentation

Candidiasis of intertriginous skin occurs as poorly marginated, bright red plaques with satellite papules and pustules scattered around the periphery of the main lesion. In some cases, pustules may also be found studded over the surface of the main plaque. The satellite pustules are 2-4 mm in diameter, whereas those superimposed over the main plaque are usually less than 1 mm in diameter. The inflammatory plaques may have a moist, slightly crusted surface and thus can appear eczematous. Candidiasis is most commonly seen in the groin hut also occasionally occurse in the axillary folds, inframammary folds, and interdigital web spaces.

In men, groin lesions are located in the inguinal-scrotal lold with later involvement of the inner thighs, gluteal cleft, and scrotum. In women, Candida vaginitis usually precedes involvement of the labia minora and majora. Spread subsequently occurs to the inner thighs and gluteal cleft.

Pruritus is generally present. When itching is followed by excoriation, pustules are disrupted, and the entire process Likes on the morphology of an eczematous disease.

A clinical diagnosis can be confirmed by KOH preparations or cultures. These studies are more likely to be positive if they are performed on material recovered from in tact pustules. Positive cultures in the absence of a positive KOH test must be. interpreted with care, since Candida sp. may colonize other inflammatory diseases occurring in intertriginous areas.

Atypical Presentations

Candidiasis of mucous membranes can appear either as white plaques or as inflammatory erosive disease. The former are frequently found in the mouth and vagina, whereas the latter is the typical appearance of Candida balanitis.

Chronic mucocutaneous candidiasis is a rare type of immunodeficiency characterized by widespread candidiasis of the skin, nails, and mucous membranes. Congenital and acquired forms exist. In either instance, the cutaneous lesions are particularly notable on the hands and feet where they simulate the papulosquamous appearance of chronic dermatophyte infection. The scalp is covered with thick yellow crusts. Pustules may be present on the scalp, face, and intertriginous skin.

Pathogenesis

Candidiasis is a yeast infection caused by Candida sp. Of these, Candida almcans accounts for most infections. The clinical picture is the same regardless of which species is responsible. C. albicans in its spore form is a normal inhabitant of the entire gastrointestinal tract. The vagina in women may be similarly colonized. Disease (in contradistinction to colonization) caused by C. albicans occurs only when there is conversion to the mycelial growth phase. This change is easily recognized on KOH preparations, but the distinction cannot, of course, be made on the basis of culture.

Development of clinical disease usually requires both the presence of damaged skin to allow for implantation and the presence of a warm moist environment. Once C. albicans has invaded the stratum corneum, it activates complement and acts as a chemotactic stimulus for polymorphonuclear leukocyte accumulation in the form of pustules. Antibiotics (by enhancing multiplication of Candida sp. in the gut) and systemically administered steroids (by reducing immunologic defense) increase the likelihood of developing candidiasis.

Therapy

Haloprogin (Halotex) and the imidazoles applied twice a day are effective in the treatment of candidiasis. Nystatin (Mycostatin) was widely used in the past, but it is less effective than currently available medications. In those patients for whom inflammation is prominent or pruritus is severe, the addition of a topically applied steroid such as hydrocortisone reduces the discomfort and shortens the time for healing. Alternatively, the combination of an antifungal agent and topical steroid packaged together as Lotrisone cream could also be used, though many believe that the high potency of the steroid used actually hampers healing. Orally administered ketoconazole is only rarely indicated in uncomplicated cases. Attention should be given to environmental factors: the skin should be kept cool, dry, and free from trauma. In women with involvement of the groin, concomitant treatment of the vagina is also necessary. In women with recurrent infections, orally administered ketoconazole in a dose of 200 mg/ day for 2 weeks may reduce the number of organisms in the gut and vagina and thus decrease reseeding onto adjacent vulvar tissue. Oral therapy with fluconazole is rarely indicated in immunocompetent patients.